Waters Edge Health and Rehab: Therapy Delays After Falls - WI
The resident, identified in inspection records only as R11, has severely impaired cognitive skills, short and long-term memory deficits, and moderate depressive symptoms. R11 wanders every day and rejects care. R11 is also independent for mobility and transfers, meaning R11 moves through the facility without assistance, which inspectors noted makes the ongoing falls particularly concerning.
A physician ordered physical therapy, occupational therapy, and speech therapy evaluations on September 11, 2025. Speech therapy completed a screen that same day and determined that, given the severity of R11's disability and a nothing-by-mouth status, no treatment was indicated. But occupational therapy and physical therapy did not complete their screens until September 22 — eleven days later.
When they finally did, they didn't examine R11 at all.
The unsigned therapy screen completed September 22 was based on existing documentation, not a physical reassessment of the resident after what inspectors described as a lengthy hospitalization. The screen concluded R11 would not benefit from skilled therapy services, citing baseline functional mobility and aggressive behaviors that made participation unsafe.
Inspectors found that no therapy discipline went back to reassess R11 after that. They relied entirely on what had already been written down.
On September 24, the surveyor raised the issue directly with the Nursing Home Administrator, the Director of Nursing, and two regional operations directors. The surveyor noted that given the number of falls R11 continued to have, it was concerning that occupational therapy and physical therapy had not been involved in developing new interventions to prevent them. The facility provided no explanation for the delay.
The Rehabilitation Director, identified as Therapy Director-VV, told the surveyor on September 24 that a screen or evaluation should be completed within three days of a physician order. Five days later, on September 29, the same director said there typically should not be a delay. When asked who had ordered therapy services on September 11, the director said she did not know.
That answer — "I don't know" — sat at the center of what inspectors documented. A physician order existed. Eleven days passed. The screens that eventually happened were done on paper. And the person overseeing rehabilitation at the facility could not account for any of it.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. That classification reflects the regulatory floor, not necessarily the experience of a resident who wanders into hallways, falls without new interventions in place, and spent nearly two weeks waiting for a therapy team to take a fresh look at what she needed after coming back from the hospital.
R11's records show moderate depression, daily wandering, physical behaviors that intrude on others, and a history of rejecting care. Returning from a hospitalization in that condition, with a physician who thought enough had changed to order new evaluations across three therapy disciplines, and then receiving nothing for eleven days — and then receiving a paper review instead of an examination — is the sequence inspectors put in writing.
The facility had no answer for why it happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters Edge Health and Rehabilitation Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
Waters Edge Health and Rehabilitation Center in KENOSHA, WI was cited for violations during a health inspection on September 30, 2025.
R11 wanders every day and rejects care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.